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MANILLA HEALTHCARE SERVICES

Manilla Healthcare Application Form

The information you supply on this form will be treated in confidence.

* indicated fields must be completed

SECTION 1 - Personal Details

Post Applied For*

Title*

Name*

Surname*

Please enter, if you ever known by any other name

Street Address*

City*

County / State / Region*

Post Code*

Country*

Home Telephone

Mobile Telephone*

Email*

Sex*

Date of Birth*

Are you aged 18 years or over?*

National Insurance Number (NI)*

Are you eligable to work in the UK?*

Disclosure and Barring Service (DBS) Certified*

Do you have a current full driving licence?*

Do you have your own transport?*

SECTION 2 - Rehabilitation of Offenders Act

Have you ever been convicted of a criminal offence?*

Have you any prosecutions pending?*

If yes! please provide details of Offence(s) and Sentence

(This information will be disclosed by the Criminal Records Bureau check which will be required if successful. Please note a criminal record will not necessarily be a bar to employment)

SECTION 3 - Health

Number of days absent in the last 2 years*

Are you registered disabled?*

If yes! please provide your disability number and details

SECTION 4 - Education

Education and Training

Please list your qualifications in reverse order, starting with the most recent first. Also, include any training that you have received which did not lead to a qualification but which you feel is relevant to the post. If short-listed for an interview, please be prepared to bring original copies of any certificates relating to post-school qualifications or vocational qualifications.

1- Date Obtained*

1- Place of study & address*

1- Examinations taken & grades*

2- Date Obtained

2- Place of study & address

2- Examinations taken & grades

3- Date Obtained

3- Place of study & address

3- Examinations taken & grades

4- Date Obtained

4- Place of study & address

4- Examinations taken & grades

Other Qualifications

Please give details of any other qualifications obtained or relevant courses attended.

1- Date Obtained*

1- Place of study & address*

1- Examinations taken & grades*

2- Date Obtained

2- Place of study & address

2- Examinations taken & grades

3- Date Obtained

3- Place of study & address

3- Examinations taken & grades

4- Date Obtained

4- Place of study & address

4- Examinations taken & grades

SECTION 5 - Employment Record

Please list chronologically, starting with current or last employer

Please give summary details of all your previous employment (most recent first for a minimum of 10 years if Applicable). Please ensure you include all part-time and temporary positions held, even those that are not relevant to your application. Please ensure you include any periods of unemployment or any other time that is not accounted for.

Employment Record

1- Name of Employer*

1- Employer Address*

1- Length of Employment*

1- Salary*

1- Date From*

1- Date to*

1- How much notice are you required to give?*

1- Reason for leaving or seeking new employment*

1- Main Duties and responsibilities*

2- Name of Employer

2- Employer Address

2- Salary

2- Length of Employment

2- Date From

2- Date to

3- Name of Employer

3- Employer Address

3- Salary

3- Length of Employment

3- Date From

3- Date to

4- Name of Employer

4- Employer Address

4- Salary

4- Length of Employment

4- Date From

4- Date to

5- Name of Employer

5- Employer Address

5- Salary

5- Length of Employment

5- Date From

5- Date to

SECTION 6 - Reference

Please give the names and addresses of your two most recent employers (if applicable). If you are unable to do this, please clearly outline who your referees are.

1- Name of Reference*

1- Their Position (Job Title)*

1- Work Relationship*

1- Organisation*

1- Telephone No*

1- Address*

1- Postcode*

1- Email*

1- May we contact your references prior to job offer?*

2- Name of Reference*

2- Their Position (Job Title)*

2- Work Relationship*

2- Organisation*

2- Telephone No*

2- Address*

2- Postcode*

2- Email*

2- May we contact your references prior to job offer?*

SECTION 7 - Emergency Contacts

1- Name*

1- Last Name*

1- Telephone Number*

1- Email*

1- Address*

2- Name

2- Last Name

2- Telephone Number

2- Email

2- Address

3- Name

3- Last Name

3- Telephone Number

3- Email

3- Address

SECTION 8 - Personal Attributes

Please give details

SECTION 9 - Declaration

I confirm that the information provided in this application (and within my Curriculum Vitae if applicable) is both truthful and accurate. I have omitted no facts that could affect my employment. I understand that any false misleading statements could place any subsequent employment in jeopardy. I understand that any employment entered into is subject to documentary evidence of my right to work in the UK and satisfactory references. I expressly consent to personal data contained within this form being recorded for the purposes of assessing suitability for the post and may form the basis of any subsequent personnel file.

Signed*

Date*

MANILLA Healthcare Services undertakes that it will treat any personal information that you provide to us, or that we obtain from you, in accordance with the requirements of the Data Protection Act 1998. After initial assessment, MANILLA Healthcare Services opportunities that may arise in the future. Please select if you do not wish us to hold your details.*

File formats: PDF, DOC, DOCX, JPG, JPEG / Maximum file size: 5 MB / Maximum number of files: up to 10 Files

Upload CV & Documents

SECTION 10 - Recruitment Monitoring Form

This sheet will be separated from your application form upon receipt and does not form part of the selection process. It will be retained by Human Resources purely for monitoring purposes.

Application for the post of

To help us ensure that our Equal Opportunities Policy is fully and fairly implemented please COMPLETE THIS SECTION OF THE APPLICATION FORM.

What is your Ethnic Group?

Ethnic Group*

Section Break

Gender*

Are you registered disabled?*

Age Group*

Media

Please state where you saw the advertisement from.

Asylum and Immigration Act 1996

It is now a requirement that before any offer of employment can be made, all candidates are to provide confirmation of their eligibility to work in the UK. Please bring one of the following original documents with you if invited to interview: a passport or an immigration and nationality directorate application registration card which evidence the right to work in the UK or a UK residence permit issued to an EEA national which confirms right of entry to or residence in the UK.

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